Revisions to the North Carolina birth certificate and their impact on tracking maternal and infant health data

No. 19 June 2012
Revisions to the North Carolina Birth Certificate and
Their Impact on Tracking Maternal and Infant Health Data
by
Kathleen A. Jones-Vessey
Approximately every 10 to 15 years, standards for
collecting statistical information on U.S. birth certificates
are revised. These revised standards specify the data fields
collected on birth certificates and information that should
be reported to the Vital Statistics Cooperative Program
(VSCP). These standards serve as a model to ensure that
birth data are collected and reported in a uniform and
comparable manner across the United States. The latest
revision to the U.S. Standard Birth Certificate, finalized
in 2003, was devised by an advisory panel of experts
which included representatives from the National Center
for Health Statistics (NCHS), the Centers for Disease
Control and Prevention (CDC), state vital registration
and statistics executives, researchers and a variety of
interested data user organizations, such as the American
Medical Association (AMA) and the American Congress
of Obstetricians and Gynecologists (ACOG).1,2
From 1988 to 2010, the statistical information collected
on North Carolina’s birth certificates were based on the
1989 U.S. Standard Birth Certificate and entered into a
DOS-based electronic birth certificate (EBC) registration
system. The magnitude of the changes required to meet
the 2003 revised birth certificate standards necessitated
that North Carolina develop a more sophisticated birth
registration system. After years of complex system
development, in August 2010, the North Carolina’s Vital
Records office launched the web-based “Vital Records
Automation System” (VRAS) in delivery hospitals across
the state. VRAS was designed to improve the timeliness
of birth registration and Vital Statistics data dissemination
as well as to implement the 2003 U.S. certificate
standards.
Many of the data fields captured on the 2003 revised
birth certificate are modified or new. The purpose of this
report is to describe the new or modified information
collected on the 2003 revised version of the birth
certificate and highlight any significant differences with
the data fields captured on the previous version of the
birth certificate.
New Fields Collected on the North
Carolina Birth Certificate
● Facility and Attendant NPI [Items 31 and 32]:
As part of the Health Insurance Portability and
Accountability Act of 1995 (HIPAA), identifying
information on health care providers are collected
by the Centers for Medicare and Medicaid Services
Statistical Primer No. 19 ♦ June 2012 Division of Public Health
N.C. Department of Health and Human Services 2 State Center for Health Statistics
(CMS) and each provider is given a unique 10 digit National Provider Identifier (NPI).3 The revised birth certificate now includes NPI for the attendant as well as the facility where the delivery took place. The inclusion of NPI on the new birth certificate will facilitate linkage of the birth file with other healthcare databases.
● Pre-pregnancy Height and Weight [Items 36 and 37]: Obesity is a growing epidemic in North Carolina. According to the 2010 North Carolina Behavioral Risk Factor Surveillance System survey, over half (55%) of North Carolina women of childbearing age are classified as overweight or obese based on their Body Mass Index (BMI).4 Women who are obese during pregnancy may be at increased risk for a Cesarean section (C-section) delivery, longer hospital stays after delivery, gestational hypertension and diabetes, fetal death and birth defects.5 The previous version of the certificate recorded information regarding weight gain during pregnancy. However, without knowing pre-pregnancy weight and height, it was impossible to determine if the amount of weight gained during pregnancy was appropriate. As a result of increasing rates of obesity among women of childbearing age, current guidelines suggest that women who are overweight or obese going into pregnancy may not need to gain as much weight as women with normal BMI’s.6 The revised birth certificate collects information on the mother’s height, pre-pregnancy weight and weight at delivery. Using this data, weight gained during pregnancy can be computed and BMI can be calculated. This information will be used to report population-level information regarding obesity and the percentage of women gaining the appropriate amount of weight during pregnancy.
32
.ATTENDANT'S NAME, TITLE, AND NPINAME:----------------------------------------------------------------------------NPI:-----------------------------------------TITLE:MDDOCNM/CMOTHER MIDWIFEOTHER (Specify)------------------------------------------------31. FACILITY ID. (NPI)Items 31 and 3236.MOTHER'S HEIGHT37. MOTHER'S PREPREGNANCY------------------(feet/inches) WEIGHT ---------------(pounds)Items 36 and 37Item 3939. DID MOTHER GET WIC FOOD FORHERSELF DURING THIS PREGNANCY? YesNo
● Women, Infants and Children (WIC) During Pregnancy [Item 39]: WIC is a federal program that provides supplemental food, healthcare referrals and nutrition education for low-income pregnant, breastfeeding and postpartum women, and infants and children up to age 5 who are at nutritional risk.7 Prenatal WIC participation has been found to be associated with improved birth outcomes for disadvantaged women.8,9 The revised birth certificate includes a field for capturing whether the mother received WIC food for herself during pregnancy. Since 1988, the State Center for Health Statistics (SCHS) staff have performed an annual match of birth certificate data with state WIC records to gather information on this population. WIC information collected from the revised birth certificate will be compared with the matched data in order to assess the completeness of this data.
● Payment for Delivery [Item 43]: The revised birth certificate includes a field for capturing the principal source of payment for the delivery. Categories include private insurance, Medicaid, self-pay, and other (specified) insurance. Since 1988, North Carolina SCHS staff have matched all resident birth records with North Carolina Division of Medical Assistance Medicaid claims and enrollment files in order to determine deliveries paid by Medicaid.10 SCHS will use this matched
43
.PRINCIPAL SOURCE OFPAYMENT FOR THISDELIVERYPrivate InsuranceMedicaidSelf-PayOther(Specify)--------------------Item 43Statistical Primer No. 19 ♦ June 2012 Division of Public Health
N.C. Department of Health and Human Services 3 State Center for Health Statistics
data to compare with this information collected on the birth certificate in order to assess the completeness of this data.
● Mother’s Medical Record Number [Item 45]: The birth certificate is used as a basis for a variety of surveillance programs, including immunizations, newborn screening and birth defects. The addition of mother’s medical record number will facilitate data linkage with other health records, as well as ensure that maternal hospital records can be accessed without difficulty.
● Gestational Diabetes [Item 46]: The previous version of the birth certificate included a checkbox for maternal diabetes in the medical history section. However, there was no way to determine if the diabetes was pre-existing or developed during the pregnancy. In order to address this, the revised birth certificate now includes two separate fields for recording diabetes in the “Pregnancy Risk Factors” section. The first collects information for mothers who had diabetes prior to pregnancy. The second field is for mothers that developed high blood sugar during pregnancy (known as “gestational diabetes”). Mothers with gestational diabetes are at increased risk for birth injury, C-section delivery, high blood pressure during pregnancy and Type II (adult onset) diabetes in the future. Infants born to mothers with gestational diabetes are at increased risk for low blood sugar and infant death.11,12
● Fertility Treatments [Item 46]: The revised birth certificate now collects information regarding whether the pregnancy resulted from infertility treatment(s). This information is recorded through two separate fields. The first is a field for the use of fertility enhancing drugs, artificial insemination or intrauterine insemination. The second field is for the use of assisted reproductive technology such as in vitro fertilization (IVF) or gamete intrafallopian transfer (GIFT). Pregnancies achieved through infertility treatments may be at increased risk for multiple pregnancies which in turn, may place the mother at increased risk of complications, as well as greater risk of preterm, low birthweight and infant death.13,14 Utilizing data collected from the revised birth certificate, the State Center for Health Statistics will be able to assess the impact of fertility treatments on maternal and infant outcomes in North Carolina.
● Previous Cesarean Section [Item 46]: Cesarean sections have risen throughout the United States over the last decade.15 Women who have had prior C-sections are more likely to have another with subsequent deliveries. On the previous version of the birth certificate, the only method for determining whether a mother had a previous C-section was via the method of delivery (vaginal after C-section or repeat C-section). The revised birth certificate now includes an indicator for whether a mother had previous C-section(s) and for recording the number of previous C-sections.
● Infections During Pregnancy [Item 47]: The revised birth certificate includes a new section focusing on maternal infections present and/or treated during pregnancy. Specifically, it captures information on the following communicable diseases: gonorrhea, syphilis, chlamydia and hepatitis (B and C). Additionally, North Carolina
45.
MOTHER'S MEDICAL RECORD NUMBERItem 4546.RISK FACTORS IN THIS PREGNANCY(Check all that apply)DiabetesPrepregnancy (Diagnosis prior to this pregnancy)Gestational (Diagnosis in this pregnancy)HypertensionPrepregnancy (Chronic)Gestational (PIH, preeclampsia)EclampsiaPrevious preterm birthOther previous poor pregnancy outcome (Includesperinatal death, small-for-gestational age/intrauterine growth restricted birth)Pregnancy resulted from infertility treatment--If yes,check all that apply:Fertility-enhancing drugs, Artificial inseminationor Intrauterine inseminationAssisted reproductive technology (e.g., in vitrofertilization (IVF), gamete intrafallopian transfer(GIFT)Mother had a previous cesarean deliveryIf yes, how many ----------------None of the aboveItem 46Statistical Primer No. 19 ♦ June 2012 Division of Public Health
N.C. Department of Health and Human Services 4 State Center for Health Statistics
chose to add a field for recording testing for the Hepatitis B surface antigen (HBsAG)—including the test date and test results. Infants born to mothers with Hepatitis B infections are more likely to be born low birth weight and/or premature.16 The U.S. Preventive Task Force has concluded that HBV screening reduces perinatal transmission of HBV and recommends that all pregnant women be tested for HBV infection during their first prenatal visit.17 North Carolina Division of Public Health staff will use this information to assess whether HBV screening is taking place, as well as to determine the prevalence of prenatal infections.
● Maternal Morbidity [Item 52]: Another new section included on the revised birth certificate focuses on maternal complications associated with labor and delivery. This section includes fields for recording whether the mother required a transfusion, had a severe perineal laceration, ruptured uterus, unplanned hysterectomy, admission to the intensive care unit or an unplanned operating room procedure following delivery. None of this information was collected on the previous version of the certificate. Maternal labor and delivery complications can increase the costs associated with labor and delivery and may also put the mother at increased risk for postpartum complications and even death.18
● NICU Admission [Item 57]: The “Abnormal Conditions of the Newborn” section of the revised birth certificate now includes a field for whether or not the infant was admitted to the Neonatal Intensive Care Unit (NICU). This information has never been available at the state level and will allow Division of Public Health staff to determine the percentage of North Carolina newborns that require higher levels of care after delivery and might be at risk for morbidity, developmental delays and infant death.
● Infant Death [Item 60]: Infant mortality is considered one of the most important indicators of population health and well-being.19 In order to better understand the factors associated with infant death, the State Center for Health Statistics routinely matches all infant deaths with their matching birth certificate. Most infant deaths occur within the first few hours or days of life. In order to track infant deaths more quickly, the revised birth certificate now includes a field for recording whether the infant was living at the time the birth certificate was filed.
47.
INFECTIONS PRESENT AND/OR TREATED DURINGTHIS PREGNANCY (Check all that apply)GonorrheaSyphilisChlamydiaHepatitis BHepatitis CNone of the aboveWas mother tested for HBsAG? YesNoIf tested, include test date----------/----------/-------------------- MM DD YYYYand test results: PositiveNegativeItem 4752.MATERNAL MORBIDITY (Check all that apply)(Complications associated with labor and delivery)Maternal transfusionThird or fourth degree perineal lacerationRuptured uterusUnplanned hysterectomyAdmission to intensive care unitUnplanned operating room procedure followingdeliveryNone of the aboveItem 52Item 5757.ABNORMAL CONDITIONS OF THE NEWBORN(Check all that apply)Assisted ventilation required immediately followingdeliveryAssisted ventilation required for more than six hoursNICU admissionNewborn given surfactant replacement therapyAntibiotics received by the newborn for suspectedneonatal sepsisSeizure or serious neurologic dysfunctionSignificant birth injury (skeletal fracture(s),peripheral nerve injury, and/or soft tissue/solidorgan hemorrhage which requires intervention)None of the above60.IS INFANT LIVING AT TIME OF REPORT? YesoNInfant transferred, status unknownItem 60Statistical Primer No. 19 ♦ June 2012 Division of Public Health
N.C. Department of Health and Human Services 5 State Center for Health Statistics
● Breastfeeding at Discharge [Item 61]: The U.S. Preventive Service Task Force concludes that there are “substantial health benefits for children and adequate evidence that breastfeeding provides moderate health benefits for women.” The Task Force recommends that interventions be put in place to support the initiation, duration and exclusivity of breastfeeding.20 Promoting breastfeeding is also a national public health priority. Healthy People 2020 includes several objectives related to increasing the proportion of infants who are breastfed.21 In an effort to track the prevalence of breastfeeding initiation, the revised birth certificate now records whether the newborn was being breastfed at hospital discharge. This data will allow North Carolina public health programs to track statewide, population-level, breastfeeding initiation rates for the first time.
Modified Fields Collected on the North Carolina Birth Certificate
In addition to new fields, the 2003 standard birth certificate also modified many of the existing demographic and medical information collected on the birth certificate. In many cases, these changes make comparisons between data collected under the previous version of the certificate and data collected under the revised certificate not comparable. Below are a list of fields which were modified with the revised birth certificate:
● Birthweight [Item 17]: On the previous version of the certificate birthweight was collected in pounds and ounces. On the revised certificate birthweight can be reported in grams or pounds and ounces.
● Mother’s and Father’s Race* [Items 20 and 21]: Prior to the 2003 revision, the race field on the birth certificate was open-ended and asked for the “Color or Race“ of both the mother and the father. The revised certificate does not mention color, specifies 15 discrete racial categories plus a category for “other,” and allows for the selection of more than one race.22,23 The 2003 revised birth certificate ethnicity reporting standards meet the race reporting standards defined by the Office of Management and Budget (OMB) in 1997.24 One additional change in race coding has also occurred. The National Center for Health Statistics (NCHS) population data sources do not include multiple race categories, therefore NCHS creates a crosswalk that “bridges” these multiple race categories back to a single race through imputation for the purposes of calculating consistent Vital Statistics rates.25 As part of this bridging process, race recorded for those of
61
.IS THE INFANT BEING?EGRAHCSIDTADEFTSAERB YesNoItem 6117. BIRTHWEIGHT (grams preferred, specify unit)------------------------------------------------------------ grams zo/bl Item 1720.FATHER'S RACE (Check one or more races to indicate what the father considers himself to be)WhiteBlack or African AmericanAmerican Indian or Alaska Native(Name of the enrolled or principal tribe)--------------------------------------------------Asian IndianChineseFilipinoJapaneseKoreanVietnameseOther Asian(Specify)-----------------------------------------Native HawaiianGuamanian or ChamorroSamoanOther Pacific Islander(Specify)-----------------------------------------------Other(Specify)------------------------------------------------21.MOTHER'S RACE (Check one or more races to indicate what the mother considers herself to be)WhiteBlack or African AmericanAmerican Indian or Alaska Native(Name of the enrolled or principal tribe)--------------------------------------------------Asian IndianChineseFilipinoJapaneseKoreanVietnameseOther Asian(Specify)-----------------------------------------Native HawaiianGuamanian or ChamorroSamoanOther Pacific Islander(Specify)-----------------------------------------------Other(Specify)-----------------------------------------------Items 20 and 21Statistical Primer No. 19 ♦ June 2012 Division of Public Health
N.C. Department of Health and Human Services 6 State Center for Health Statistics
Hispanic ethnicity has also been modified. Under race coding specifications for the previous version of the birth certificate, if a mother or father reported their race as “Hispanic,” NCHS guidelines typically stipulated that their race be classified as white. Under the 2003 revised race coding standards, the majority of Hispanics are now classified as “other races.”26 Due to this change in race coding for Hispanics, all reports based on North Carolina birth data will now be required to combine race/ethnicity (e.g., Non-Hispanic white, Non-Hispanic black, Hispanic, etc.).
● Mother’s and Father’s Ethnicity* [Items 25 and 28]: Race and ethnicity are recorded in two separate fields on both versions of the birth certificate. On the previous version of the birth certificate, ethnicity was a “yes/no” field that was followed by a separate question which specified the origin for those indicating that they were Hispanic. On the revised birth certificate, ethnicity and origin are recorded in the same field. The 2003 revised birth certificate ethnicity reporting standards meet the race and ethnicity reporting standards defined by the Office of Management and Budget (OMB) in 1997.24 The order of the race and ethnicity questions were also modified. Prior to generating the birth certificate, the mother is given a worksheet to fill out that includes demographic questions, such as race and ethnicity. On the mother’s worksheet, the ethnicity question is now asked prior to the race question, in an effort to improve the reporting of race for Hispanics.27
● Mother’s and Father’s Education* [Items 26 and 29]: The previous version of the birth certificate captured education levels by asking for the years of schooling completed. However, this method did not necessarily reflect degrees or diplomas received.27 To address this problem, the 2003 revision instead breaks secondary education into separate fields (8th grade or less, 9–12th grade, high school graduate or GED) and allows for reporting of specific degrees received (Associate, Bachelor’s, Master’s or Doctorate). Since education information is collected very differently on the two versions of the certificates, this field is not considered comparable across the two certificate revisions.
25.
FATHER OF HISPANIC ORIGIN? (Check thebox that best describes whether the father isSpanish/Hispanic/Latino. Check the "No" box iffather is not Spanish/Hispanic/Latino)No, not Spanish/Hispanic/LatinoYes, Mexican, Mexican American, ChicanoYes, Puerto RicanYes, CubanYes, other Spanish/Hispanic/Latino(Specify)----------------------------------------------28.MOTHER OF HISPANIC ORIGIN? (Check thebox that best describes whether the mother isSpanish/Hispanic/Latina. Check the "No" box ifmother is not Spanish/Hispanic/Latina)No, not Spanish/Hispanic/LatinaYes, Mexican, Mexican American, ChicanaYes, Puerto RicanYes, CubanYes, other Spanish/Hispanic/Latina(Specify)----------------------------------------------Items 25 and 2826.FATHER'S EDUCATION (Check the box thatbest describes the highest degree or level ofschool completed at the time of delivery)8th grade or less9th - 12th grade, no diplomaHigh school graduate or GED completedSome college credit but no degreeAssociate degree (e.g., AA, AS)Bachelor's degree (e.g., BA, AB, BS)Master's degree (e.g., MA, MS, MEng, MEd,MSW, MBA)Doctorate (e.g., PhD, EdD) or Professionaldegree (e.g., MD, DDS, DVM, LLB, JD)29.MOTHER'S EDUCATION (Check the box thatbest describes the highest degree or level ofschool completed at the time of delivery)8th grade or less9th - 12th grade, no diplomaHigh school graduate or GED completedSome college credit but no degreeAssociate degree (e.g., AA, AS)Bachelor's degree (e.g., BA, AB, BS)Master's degree (e.g., MA, MS, MEng, MEd,MSW, MBA)Doctorate (e.g., PhD, EdD) or Professionaldegree (e.g., MD, DDS, DVM, LLB, JD)Items 26 and 29
* In North Carolina, in cases where the mother was unmarried at the time of delivery, paternity must be established before the father’s information can be collected on the birth certificate. In 2010, 42 percent of all North Carolina births were to unwed mothers and 40 percent of these were missing father’s information on the birth certificate. For this reason, any demographic information collected for the father on the birth certificate (such as age, race, ethnicity, education and birth place) has a high rate of non-random missing data and is not suitable for analysis.Statistical Primer No. 19 ♦ June 2012 Division of Public Health
N.C. Department of Health and Human Services 7 State Center for Health Statistics
● Place of Birth [Item 30]: The previous version of the certificate recorded information on place of birth which included hospital, freestanding birth center, clinic/doctors office, residence and other (specified). When deliveries occurred at a residence, it was difficult to determine whether the home birth was planned or unanticipated.27 To remedy this, the revised birth certificate changes the “residence” checkbox to “home birth” and includes a field for indicating whether the home birth was planned or not. Research indicates that unplanned home births have higher rates of adverse maternal and infant outcomes.28,29 Information regarding planned and unplanned home births in conjunction with information on the attendant at delivery will allow us to examine North Carolina home births in more detail.
● Attendant [Item 32]: The delivery attendant was recorded on both the 1989 and the 2003 standard certificates. The previous version of the certificate included the following attendant categories: Medical Doctor (M.D.), Doctor of Osteopathy (D.O.), Certified Nurse Midwife (C.N.M.), Other Midwife, and Other specified. The only change made to this field was the addition of “Certified Midwife” (C.M.) to the “Certified Nurse Midwife” (C.N.M.) checkbox. The revised certificate now includes: “C.N.M/C.M.” in the same checkbox. The American College of Nurse Midwives recommended this change because the licensing for both C.N.M.’s and C.M.’s are the same.27 This field will be used to better assess trends in delivery attendants over time, particularly the rise in CNM-attended deliveries. In 1990, C.N.M.’s attended 1.7 percent of North Carolina resident births, compared with 11 percent of all births in 2010.30,31
● Maternal Transfer [Item 33]: Both versions of the standard certificate report whether the mother was transferred prior to delivery, as well as the hospital of transfer. However the revised birth certificate added the stipulation: “for maternal medical or fetal indications for delivery.”
● Prenatal Care [Items 34a, 34b and 35]: The previous version of the certificate included a field for capturing the month that a mother initiated prenatal care. The revised certificate now asks for the complete date of the first prenatal care visit (month/day/year). The advisory group that made recommendations for the 2003 revised birth certificate felt that collecting the specific date care began would yield more accurate prenatal care data.27 The accuracy of this field is important as early initiation of prenatal care can help identify health conditions and risk factors which might impact the health of both the mother and infant.32,33
30
.PLACE WHERE BIRTH OCCURRED (Check one)HospitalFreestanding birthing centerHome Birth:Planned to deliver at Home? Yes NoClinic/Doctor's officeOther (Specify) ------------------------------------------Item 3032.ATTENDANT'S NAME, TITLE, AND NPINAME:----------------------------------------------------------------------------NPI:-----------------------------------------TITLE:MDDOCNM/CMOTHER MIDWIFEOTHER (Specify)------------------------------------------------Item 3233.MOTHER TRANSFERRED FOR MATERNAL MEDICALOR FETAL INDICATIONS FOR DELIVERY? Yes NoIF YES, ENTER NAME OF FACILITY MOTHERTRANSFERRED FROM:-----------------------------------------------------------------------------------Item 33Items 34a, 34b and 3534a.DATE OF FIRST PRENATAL CARE VISIT34b. DATE OF LAST PRENATAL CARE VISIT35. TOTAL NUMBER OF PRENATAL VISITS FOR THIS PREGNANCY----------/----------/-------------------- No Prenatal Care ----------/----------/-------------------- ---------------------------------------- (If none, enter "0".) MM DD YYYY MM DD YYYYStatistical Primer No. 19 ♦ June 2012 Division of Public Health
N.C. Department of Health and Human Services 8 State Center for Health Statistics
● Weight at Delivery [Item 38]: The previous version of the certificate recorded information regarding weight gain during pregnancy. The revised birth certificate now collects information on the mother’s height and pre-pregnancy weight which are used in conjunction with the mother’s weight at delivery to calculate weight gained during pregnancy to determine if the mother gained the appropriate amount of weight during pregnancy. Research suggests that excessive weight gain during pregnancy leads to an increased risk of pregnancy complications, Cesarean section delivery and longer hospital stays after delivery.34
● Other Pregnancy Outcomes [Item 41]: Both versions of the birth certificate report whether the mother had prior fetal deaths, abortions or miscarriages. The previous version of the birth certificate reported the number of “other terminations (spontaneous and induced at any time after conception).” The revised birth certificate reports the number of “other pregnancy outcomes (spontaneous or induced losses or ectopic pregnancies).”
● Cigarette Smoking [Item 42]: Smoking during pregnancy may put women at increased risk for vaginal bleeding, placental problems, miscarriage and stillbirth. Infants born to mothers who smoked during pregnancy are more likely to have certain birth defects, be born premature and/or low birthweight and die from Sudden Infant Death Syndrome (SIDS).35,36 The previous version of the birth certificate included a “yes/no” checkbox regarding tobacco use during pregnancy and a separate field for recording the average number of cigarettes smoked per day. However, there was no means to determine whether the mother smoked prior to becoming pregnant or whether she ceased smoking at some point during her pregnancy. Research suggests that smoking cessation during pregnancy can reduce the incidence of low birth weight and hospital associated costs.37,38 The revised birth certificate includes fields for recording smoking status three months before pregnancy as well as during each trimester of pregnancy. This method of collecting smoking information on the revised birth certificate was selected based on research which determined that this was the most effective way to gather accurate maternal smoking behavior.39,40 Given the substantial changes in how this field is defined, the National Center for Health Statistics does not consider this field to be comparable with data collected through the previous version of the certificate.41
● Previous Preterm Birth [Item 46]: On the previous version of the birth certificate, there was a checkbox in the “Medical History for this Pregnancy” section for “previous preterm or small-for-gestational-age infant.” The revised certificate reports this in the “Risk Factors for This Pregnancy” section as: “previous preterm birth” and includes a separate check box for “other previous poor pregnancy outcome (includes perinatal death, small-for-gestational age/intrauterine growth restricted birth).”
● Hypertension [Item 46]: The previous version of the certificate included check-boxes in the “Medical History for this Pregnancy” section for chronic hypertension, pregnancy-related hypertension and eclampsia. The revised certificate reports hypertension in the “Risk Factors for This Pregnancy” section and labels them as prepregnancy (chronic), gestational (PIH, preeclampsia) and eclampsia.
38.
MOTHER'S WEIGHT AT DELIVERY----------------(pounds)Item 3841.NUMBER OF OTHERPREGNANCY OUTCOMESdecudni ro suoenatnops(losses or ectopic pregnancies)41a. Other Outcomes Number -----------None41b. DATE OF LAST OTHER PREGNANCY OUTCOME----------/----------MMYYYYItem 4142.CIGARETTE SMOKING BEFORE AND DURING PREGNANCYFor each time period, enter either the number of cigarettes or thenumber of packs of cigarettes smoked. IF NONE, ENTER "0"Average number of cigarettes or packs of cigarettes smoked per day. # of cigarettes # of packsThree months before pregnancy_____OR______First three months of pregnancy_____OR______Second three months of pregnancy_____OR______Third trimester of pregnancy_____OR______Item 42Statistical Primer No. 19 ♦ June 2012 Division of Public Health
N.C. Department of Health and Human Services 9 State Center for Health Statistics
● Onset of Labor [Item 49]: The information collected in the “Onset of Labor” section of the revised birth certificate were previously collected in the “Events of Labor and Delivery” section of the previous version of the birth certificate.
● Characteristics of Labor and Delivery [Item 50]: Induction of labor and meconium were previously collected in the obstetrical procedures section of the previous version of the birth certificate. “Non vertex presentation” was collected as “breech/malpresentation” in the “events of labor and delivery” section of the previous version of the birth certificate. “Clinical chorioamnionitis diagnosed during labor” was collected as “febrile >100F or 38C” on the previous version of the birth certificate.
● Method of Delivery [Item 51]: The previous version of the certificate included a checkbox for method of delivery which had fields for vaginal, vaginal birth after C-section, Primary C-section, Repeat C-section, forceps and vacuum deliveries (certifiers could check all that applied). The revised certificate includes additional information regarding fetal presentation (cephalic, breech, other), whether forceps delivery was attempted and unsuccessful, whether vacuum delivery was attempted but unsuccessful and whether a trial of labor was attempted prior to Cesarean section delivery. C-section deliveries have risen 37 percent from 22.9 percent of resident births in 1990 to 31.4 percent in 2010.30,31
46.RISK FACTORS IN THIS PREGNANCY(Check all that apply)DiabetesPrepregnancy (Diagnosis prior to this pregnancy)Gestational (Diagnosis in this pregnancy)HypertensionPrepregnancy (Chronic)Gestational (PIH, preeclampsia)EclampsiaPrevious preterm birthOther previous poor pregnancy outcome (Includesperinatal death, small-for-gestational age/intrauterine growth restricted birth)Pregnancy resulted from infertility treatment--If yes,check all that apply:Fertility-enhancing drugs, Artificial inseminationor Intrauterine inseminationAssisted reproductive technology (e.g., in vitrofertilization (IVF), gamete intrafallopian transfer(GIFT)Mother had a previous cesarean deliveryIf yes, how many ----------------None of the aboveItem 4649.ONSET OF LABOR (Check all that apply)Premature Rupture of Membranes(prolonged,>12 hrs.)Precipitous Labor (<3 hrs.)Prolonged Labor (> 20 hrs.)None of the aboveItem 4950.CHARACTERISTICS OF LABOR AND DELIVERY(Check all that apply)Induction of laborAugmentation of laborNon-vertex presentationSteroids (glucocorticoids) for fetal lung maturationreceived by the mother prior to deliveryAntibiotics received by the mother during laborClinical chorioamnionitis diagnosed during laboror maternal temperature > 38°C (100.4°F)Moderate/heavy meconium staining of the amnioticfluidFetal intolerance of labor such that one or more ofthe following actions was taken: in-uteroresuscitative measures, further fetal assessment,or operative deliveryEpidural or spinal anesthesia during laborNone of the aboveItem 50Item 5151.METHOD OF DELIVERYA.Was delivery with forceps attempted but unsuccessful?YesNoB.Was delivery with vacuum extraction attempted butunsuccessful?YesNoC.Fetal presentation at birthCephalicBreechOtherD.Final route and method of delivery (Check one)Vaginal/SpontaneousVaginal/ForcepsVaginal/VacuumCesareanIf cesarean, was a trial of labor attempted?YesNoStatistical Primer No. 19 ♦ June 2012 Division of Public Health
N.C. Department of Health and Human Services 10 State Center for Health Statistics
● Fetal Presentation at Birth [Item 51]: The previous version of the birth certificate included a field for recording breech/malpresentation in the “events of labor and delivery section.” The revised certificate provides greater specificity regarding whether the child was cephalic, breech or other. Cesarean section delivery is typically recommended in cases of fetal malpresentation.42,43 This information will be used to assess birth and method of delivery outcomes for infants born after fetal malpresentation in North Carolina.
● Obstetric Estimate of Gestation [Item 54]: The previous version of the birth certificate labeled this field as “clinical estimate of gestation.”
● Apgar Score [Item 55]: The Apgar score is a method for quickly assessing the overall health of a newborn right after delivery. The Apgar ranks newborn health with regard to skin color/complexion, reflexes, muscle tone, breathing and pulse rate. Newborns are typically assessed within minutes after birth. The previous version of the certificate recorded both one and five minute Apgar scores. Research has concluded that one minute Apgar scores alone are not a valid predictor of an infant’s future outcome. Five minute Apgar scores have been determined to be better predictors of neonatal risk and mortality. Low Apgar scores at five minutes should be repeated every five minutes up to 20 minutes.44 As a result of this research, the revised birth certificate standard now records a five minute Apgar and only records the Apgar at 10 minutes if the five minute Apgar score was low (defined as less than six).
● Abnormal Conditions of the Newborn [Item 57]: The label for this section changed from “Conditions of the Newborn” to “Abnormal Conditions of the Newborn.” The previous version of the birth certificate included two categories for assisted ventilation: 1) <30 minutes and 2) >= 30 minutes. The revised birth certificate has two different categories: 1) ventilation required immediately following delivery and 2) ventilation required for more than six hours. The previous version of the birth certificate included a checkbox for seizures. The revised birth certificate changed this to “seizures or serious neurologic dysfunction.” The previous version of the birth certificate included a checkbox for birth injury. The revised birth certificate modifies this checkbox to: “significant birth injury” and includes examples of what this might include.
● Congenital Anomalies [Item 58]: Research suggests that congenital anomalies have not been reliably recorded on past revisions to birth certificates.45,46 In an effort to improve reporting, the Advisory Panel that devised the specifications for the 2003 birth certificate revision carefully examined deficiencies in how congenital anomalies were captured on prior certificates. According to the Advisory Panel, the 2003 revised certificate only includes anomalies that meet the following criteria: “1) the anomaly is diagnosable within the first 24 hours following birth using widely available conventional diagnostic techniques, 2) occurrence will indicate the need for a specific public health initiative, 3) occurrence serves as a potential marker for teratogen exposure, 4) occurrence in live borns is affected by prenatal diagnosis or management and 5) postnatal outcome is
Item 54
54.OBSTETRIC ESTIMATE OF GESTATION:------------------------------------ (completed weeks)Item 5555.APGAR SCORE:Score at 5 minutes: -----------------------------------If 5 minute score is less than 6,Score at 10 minutes: ---------------------------------Item 5757.ABNORMAL CONDITIONS OF THE NEWBORN(Check all that apply)Assisted ventilation required immediately followingdeliveryAssisted ventilation required for more than six hoursNICU admissionNewborn given surfactant replacement therapyAntibiotics received by the newborn for suspectedneonatal sepsisSeizure or serious neurologic dysfunctionSignificant birth injury (skeletal fracture(s),peripheral nerve injury, and/or soft tissue/solidorgan hemorrhage which requires intervention)None of the aboveStatistical Primer No. 19 ♦ June 2012 Division of Public Health
N.C. Department of Health and Human Services 11 State Center for Health Statistics
heavily impacted by access to tertiary or quaternary care resources.”27 Congenital anomaly information identified on the revised birth certificate will be compared to the North Carolina Birth Defects Monitoring Program registry data to assess if the accuracy of congenital anomaly data collected through the revised birth certificate improves as a result of these reporting changes. Specific modifications to this section include the following:
The previous version of the birth certificate had a checkbox for “anencephalus” and the revised birth certificate changes this to “anencephaly.” The previous version of the birth certificate had a checkbox for “spina bifida/meningocele” and the revised birth certificate changes this to “meningomyelocele/spina bifida.” The previous version of the birth certificate had a checkbox for “heart malformations” and the revised birth certificate changes this to “cyanotic congenital heart disease.” The previous version of the birth certificate had a checkbox for “diaphragmatic hernia” and the revised birth certificate changes this to “congenital diaphragmatic hernia.” The previous version of the birth certificate had a checkbox for “omphalocele/gastroscihsis” and the revised birth certificate separates these into two separate fields “omphalocele” and “gastroschisis.” The previous version of the birth certificate had a checkbox for “polydactyly/syndactyly/adactyly” and the revised birth certificate modifies this to just “limb reduction defect (excluding congenital amputation and dwarfing syndromes).” The previous version of the birth certificate had a checkbox for “cleft lip/palate” and the revised birth certificate separates these into two separate fields “cleft lip with or without cleft palate” and “cleft palate alone.” The previous version of the birth certificate had a checkbox for “Down’s syndrome” and the revised birth certificate includes this, but further specifies “karyotype confirmed” and “karyotype pending.” The previous version of the birth certificate had a checkbox for “other chromosomal anomalies.” The revised birth certificate also has “suspected chromosomal disorder,” and additionally specifies “karyotype confirmed” and “karyotype pending.” The revised birth certificate has a checkbox for hypospadias. On the previous version of the birth certificate this information may have been collected via two different checkboxes, one for “malformed genitalia” and another for “other urogenital anomalies.”
● Infant Transfer (Item 59): Both versions of the birth certificate include fields for reporting if the infant was transferred to another facility. The revised birth certificate further specifies whether it was “within 24 hours of delivery.”
Fields that have been Eliminated with the 2003 Revision
● Alcohol Use During Pregnancy: The previous version of the birth certificate included an indicator for whether the mother consumed alcohol during pregnancy as well as the average number of alcoholic drinks consumed per week during pregnancy. Prior research with the 1989 revision to the North Carolina birth certificate data indicated that this field was not reliably reported.47 Other research confirmed substantial underreporting and inconsistency with prenatal drinking reported on national health surveys.48 Based on this research, the Advisory Panel that created the specifications for the 2003 birth certificate revision concluded that: “it is not feasible to get quality data on the birth certificate because of the stigma attached to alcohol use during pregnancy.” The Advisory
Item 58
58.CONGENITAL ANOMALIES OF THE NEWBORN(Check all that apply)AnencephalyMeningomyelocele/Spina bifidaCyanotic congenital heart diseaseCongenital diaphragmatic herniaOmphaloceleGastroschisisLimb reduction defect (excluding congenitalamputation and dwarfing syndromes)Cleft Lip with or without Cleft PalateCleft Palate aloneDown SyndromeKaryotype confirmedKaryotype pendingSuspected chromosomal disorderKaryotype confirmedKaryotype pendingHypospadiasNone of the anomalies listed aboveItem 5959.WAS INFANT TRANSFERRED WITHIN 24 HOURS OF DELIVERY? YesNoIF YES, NAME OF FACILITY INFANT TRANSFERRED TO:--------------------------------------------------------------------------------------------------------------Statistical Primer No. 19 ♦ June 2012 Division of Public Health
N.C. Department of Health and Human Services 12 State Center for Health Statistics
panel recommended that this data be obtained from national health surveys, such as the Pregnancy Risk Assessment Monitoring System (PRAMS).27
● Medical History: Based on Advisory Panel recommendations, several maternal conditions were eliminated from this section of the certificate (in the 2003 revision, this section was relabeled “Risk Factors in this Pregnancy”). Conditions that did not meet the following criteria were eliminated: “1) clearly defined clinically, 2) collectable at least 90 percent of the time, 3) evidence-based, 4) useful for research (public health and clinical) purposes, 5) potential to effect pregnancy outcome, and 6) required by legal statute.”27 Using this criteria, the following maternal conditions were eliminated: anemia, cardiac disease, acute or chronic lung disease, genital herpes, hydramnios/obligohydramnios, hemoglobinopathy, incompetent cervix, previous infant 4000+ grams, renal disease, Rh sensitization and uterine bleeding.
● Events of Labor and Delivery: Based on Advisory Panel recommendations, this section of the certificate was also significantly modified (in the 2003 revision, this section was relabeled “Characteristics of Labor and Delivery”). The Advisory Panel recommended that the following fields be eliminated from the 2003 revised birth certificate: meconium moderate or heavy, abruption placenta, placentia previa, other excessive bleeding, seizures during labor, dysfunctional labor, cord prolapse, anesthetic complications and fetal distress.
● Conditions of the Newborn: The Advisory Panel recommended removal of newborn conditions from the birth certificate: 1) that are not easily diagnosed within the first 24 hours following delivery, 2) which do not have high associations with adverse neonatal and long-term outcomes and 3) markers for utilization of costly technological resources.27 Based on this criteria, the following newborn conditions were removed from the revised birth certificate: anemia, fetal alcohol syndrome, hyaline membrane disease/RDS and meconium aspiration syndrome.
● Congenital Anomalies: As outlined in the congenital anomalies modifications section above, the Advisory panel determined that many of the congenital anomalies reported on the previous version of the birth certificate were not reliably reported.27 As a result, the following congenital anomaly fields are no longer collected on the 2003 revised birth certificate: hydrocephalus, microcephalus, other central nervous system anomalies, other circulatory/respiratory anomalies, rectal atresia/stenosis, tracheo-esophageal fistula/esophageal atresia, other gastrointestinal anomalies, renal agenesis, other urogenital anomalies, club foot, other musculoskeletal/integumental anomalies and other chromosomal anomalies.
● Other Specified Diagnoses and Conditions: The previous version of the birth certificate collected additional diagnostic information in the “other specified” fields of the medical history, obstetric procedures, events of labor and delivery, conditions of the newborn and congenital anomalies of child sections. The revised birth certificate has eliminated these free text fields because they do not result in uniform data that can be coded and utilized by states.27
New and Modified Fields Collected for Legal and Vital Registration Purposes
Some additional fields that are not necessary for medical or health research, but are helpful for legal and vital registration purposes have also been added or modified on the revised birth certificate. Below is a list of these fields:
● Mother Last Name (Current and Prior to First Marriage) [Items 9a and 9c];
● For Unmarried mothers, whether a paternity acknowledgement was signed in the hospital [Item 22].
Reporting Data Based on the Revised Birth Certificate in North Carolina
In 2010, North Carolina’s Vital Records office began implementing a new birth registration based on the 2003 revised birth certificate standard. Training in the Statistical Primer No. 19 ♦ June 2012 Division of Public Health
N.C. Department of Health and Human Services 13 State Center for Health Statistics
new web-based birth registration system was rolled out in August 2010, hospital by hospital. By the end of 2010, all hospitals in the state were transmitting birth data to the state Vital Records office through the new registration system. As a result of this staggered implementation, North Carolina birth data were collected under both the 1989 and the 2003 birth certificate standards in 2010. Therefore, the State Center for Health Statistics was unable to publish any data from the new or modified fields for 2010 births. Fields that were not comparable across the two certificate revisions, such as maternal smoking, prenatal care and congenital anomalies were left blank in the 2010 birth file and were not reported in the 2010 Vital Statistics reports. Beginning in 2011, birth data were collected solely under the revised U.S. Standard Certificate, therefore, 2011 will represent the first full year of revised birth certificate data that North Carolina’s State Center for Health Statistics will publish. Researchers and other data users of North Carolina birth data will need to be careful not to compare trends in certain key public health indicators, such as prenatal care, race, smoking and maternal education levels, across the two revisions.
References
1. National Center for Health Statistics, Division of Vital Statistics, Reproductive Statistics Branch. 2003 Revisions of the U.S. Standard Certificates of Live Birth and Death and the Fetal Death Report. Hyattsville, MD: Available at: www.cdc.gov/nchs/nvss/vital_certificate_revisions.htm. Accessed April 12, 2012.
2. National Center for Health Statistics, Division of Vital Statistics, Reproductive Statistics Branch. The New Birth Certificate: Making Vital Statistics More Vital. Hyattsville, MD: Available at: www.cdc.gov/nchs/ppt/dvs/THE%20NEW%20BIRTH%20CERTIFICATE.ppt. Accessed April 12, 2012.
3. Centers for Medicare and Medicaid Services (CMS). National Provider Identifier Standard (NPI). Available at: www.cms.hhs.gov/Regulations-and-Guidance/HIPAA-Administrative-Simplification/NationalProvIdentStand/index.html?redirect=/NationalProvIdentStand. Accessed April 12, 2012.
4. North Carolina Department of Health and Human Services, Division of Public Health, State Center for Health Statistics. Tracking Preconception Health in North Carolina: 2010. Available at: www.schs.state.nc.us/schs/data/preconception.html. Accessed April 12, 2012.
5. Centers for Disease Control and Prevention, Reproductive Health. Pregnancy Complications. Available at: www.cdc.gov/reproductivehealth/maternalinfanthealth/PregComplications.htm. Accessed April 12, 2012.
6. National Academies, Institute of Medicine. Weight gain during pregnancy: reexamining the guidelines. Report brief, May 2009. Available at: www.iom.edu/~/media/Files/Report%20Files/2009/Weight-Gain-During-Pregnancy-Reexamining-the-Guidelines/Report%20Brief%20-%20Weight%20Gain%20During%20Pregnancy.pdf. Accessed April 12, 2012.
7. U.S. Department of Agriculture, Food and Nutrition Service. Women, Infants and Children. Available at: www.fns.usda.gov/wic. Accessed April 12, 2012.
8. Bitler M, Currie J. Does WIC Work? The Effects of WIC on Pregnancy and Birth Outcomes. Department of Economics, UCLA, June 2004. Available at: www.econ.ucla.edu/people/papers/currie/more/prams.pdf. Accessed April 12, 2012.
9. Buescher P, Horton S. Prenatal WIC participation in relation to low birth weight and Medicaid Infant Costs in North Carolina—A 1997 Update. CHIS Study: No. 122. November 2000. Available at: www.schs.state.nc.us/schs/pdf/CHIS122.pdf. Accessed April 12, 2012.
10. Buescher P. Method of linking Medicaid records to birth certificates may affect infant outcome statistics. American Journal of Public Health, April 1999;89(4): 564–6. Available at: www.schs.state.nc.us/SCHS/pdf/medicaid.pdf. Accessed April 12, 2012.
11. American Diabetes Association. Diabetes Basics: What is Gestational Diabetes? Available at: www.diabetes.org/diabetes-basics/gestational/what-is-gestational-diabetes.html. Accessed April 12, 2012.
12. National Diabetes Information Clearinghouse (NDIC). What I need to know about Gestational Diabetes. Available at: http://diabetes.niddk.nih.gov/dm/pubs/gestational/#3. Accessed April 12, 2012.
13. Welmerink D, Voigt L, Daling J, Mueller B. Infertility treatment use in relation to selected adverse birth outcomes. Fertility and Sterility. December 2010;94(7):2580–6.Statistical Primer No. 19 ♦ June 2012 Division of Public Health
N.C. Department of Health and Human Services 14 State Center for Health Statistics
14. March of Dimes. Multiple Pregnancy and Birth: Considering Fertility Treatments. Available at: www.marchofdimes.com/Fertility_treatments_and_multiple_pregnancy_PDF.pdf. Accessed April 12, 2012.
15. Menacker F, Hamilton B. Recent trends in cesarean delivery in the United States. NCHS Data Brief. 2010, No. 35. Hyattsville, MD: National Center for Health Statistics. Available at: www.cdc.gov/nchs/data/databriefs/db35.pdf. Accessed April 12, 2012.
16. American College of Obstetricians and Gynecologists. Hepatitis B in Pregnancy: Frequently Asked Questions. Available at: www.acog.org/~/media/For%20Patients/faq093.pdf?dmc=1&ts=20120410T1351526804. Accessed April 12, 2012.
17. U.S. Preventive Services Task Force. Screening for Hepatitis B Virus in Pregnancy: Reaffirmation Recommendation Statement. Dated June 2009. Available at: www.uspreventiveservicestaskforce.org/uspstf09/hepb/hepbpgrs.htm. Accessed April 12, 2012.
18. Danel I, et al. Magnitude of Maternal Morbidity During Labor and Delivery: United States, 1993–1997. Am J Public Health. 2003 April;93(4):631–4. Available at: www.ncbi.nlm.nih.gov/pmc/articles/PMC1447802. Accessed April 12, 2012.
19. Singh GK, Yu, SM. Infant mortality in the United States: trends, differentials, and projections, 1950 through 2010. Am J Public Health. 1995 July;85(7):957–64. Available at: www.ncbi.nlm.nih.gov/pmc/articles/PMC1615523. Accessed April 12, 2012.
20. U.S. Preventive Services Task Force. Primary Care Interventions to Promote Breastfeeding: Recommendation Statement. Dated October 2008. Available at: www.uspreventiveservicestaskforce.org/uspstf08/breastfeeding/brfeedrs.htm. Accessed April 12, 2012.
21. Healthy People 2020. Maternal, Infant and Child Health: Objective: MICH-21.1. Available at: http://healthypeople.gov/2020/topicsobjectives2020/objectiveslist.aspx?topicid=26. Accessed April 12, 2012.
22. Buescher P, Gizlice Z, Jones-Vessey K. Self-Reported versus Published Data on Racial Classification in North Carolina Birth Records. SCHS Study: No 139. February 2004. Available at: www.schs.state.nc.us/schs/pdf/schs139.pdf. Accessed April 12, 2012.
23. Buescher P, Gizlice Z, Jones-Vessey K. Discrepancies Between Published Data on Racial Classification and Self-Reported Race: Evidence from the 2002 North Carolina Live Birth Records. Public Health Reports. July–Aug 2005;120:393–8. Available at: www.ncbi.nlm.nih.gov/pmc/articles/PMC1497745/pdf/16025719.pdf. Accessed April 12, 2012.
24. U.S. Office of Management and Budget. Revisions to the Standards for the Classification of Federal Data on Race and Ethnicity. October 30, 1997. Available at: www.whitehouse.gov/omb/fedreg_1997standards. Accessed April 12, 2012.
25. National Center for Health Statistics, National Vital Statistics System. U.S. Census Populations With Bridged Race Categories. Available at: www.cdc.gov/nchs/nvss/bridged_race.htm. Accessed April 12, 2012.
26. National Center for Health Statistics, Division of Vital Statistics. NCHS Procedures for Multiple-Race and Hispanic Origin Data: Collection, Coding, Editing, and Transmitting. May 7, 2004. Available at: www.cdc.gov/nchs/data/dvs/multiple_race_documentation_5-10-04.pdf. Accessed April 12, 2012.
27. National Center for Health Statistics, Division of Vital Statistics. Report of the Panel to Evaluate the U.S. Standard Certificates. April 2000, Addenda Nov 2001. Available at: www.cdc.gov/nchs/data/dvs/panelreport_acc.pdf. Accessed April 12, 2012.
28. Declercq E, MacDorman MF, Menacker F, Stotland N. Characteristics of planned and unplanned home births in 19 states. Obstet Gynecol. 2010;116(1):93–9.
29. MacDorman MF, Mathews TJ, Declercq E. Home births in the United States, 1990–2009. NCHS data brief, no 84. Hyattsville, MD: National Center for Health Statistics. 2012. Available at: www.cdc.gov/nchs/data/databriefs/db84.htm. Accessed April 12, 2012.
30. North Carolina Department of Health and Human Services, Division of Public Health, State Center for Health Statistics. North Carolina Selected Vital Statistics: Volume 1—1990. Available at: www.schs.state.nc.us/schs/pdf/1990_NORTH_CAROLINA_VITAL_STATISTICS_VOLUME_1.pdf. Accessed April 12, 2012.
31. North Carolina Department of Health and Human Services, Division of Public Health, State Center Statistical Primer No. 19 ♦ June 2012 Division of Public Health
N.C. Department of Health and Human Services 15 State Center for Health Statistics
for Health Statistics. North Carolina Selected Vital Statistics: Volume 1—2010. Available at: www.schs.state.nc.us/schs/vitalstats/volume1/2010. Accessed April 12, 2012.
32. McCormick MC, Siegel E. Recent Evidence on the Effectiveness of Prenatal Care. Ambulatory Pediatrics. 2001;1(6):321,5.
33. Alexander, GR, Kotelchuck M. Assessing the Role and Effectiveness of Prenatal Care: History, Challenges, and Directions for Future Research. Public Health Reports. 2001;116(4):306–16. Available at: www.ncbi.nlm.nih.gov/pmc/articles/PMC1497343/pdf/12037259.pdf. Accessed April 12, 2012.
34. Abdullah et al. Associations of maternal pre-pregnancy obesity and excess pregnancy weight gains with adverse pregnancy outcomes and length of hospital stay. BMC Pregnancy Childbirth. 2011;11:62. Available at: www.ncbi.nlm.nih.gov/pmc/articles/PMC3178538/?tool=pmcentrez. Accessed April 12, 2012.
35. Centers for Disease Control and Prevention, Reproductive Health. Tobacco Use and Pregnancy. Available at: www.cdc.gov/reproductivehealth/tobaccousepregnancy. Accessed April 12, 2012.
36. Salihu HM, Wilson RE. Epidemiology of prenatal smoking and perinatal outcomes. Early Human Development. November 2007;83(11):713–20.
37. Marks JS, Koplan JP, Hogue CJ, Dalmat ME. Cost-benefit/cost effectiveness analysis of smoking cessation for pregnant women. American Journal of Preventive Medicine. 1990;6:282–9.
38. Lightwood JM, Phibbs C, Glantz SA. Short-term health and economic benefits of smoking cessation: low birth weight. Pediatrics. 1999;104:1312–20.
39. Ventura S. Using the Birth Certificate to Monitor Smoking During Pregnancy. Public Health Reports. January/February 1999;114:71–3. Available at: www.ncbi.nlm.nih.gov/pmc/articles/PMC1308346. Accessed April 12, 2012.
40. Kharrazi et al. Evaluation of four maternal smoking questions. Public Health Report. January-February 1999;114(1):60–70. Available at: www.ncbi.nlm.nih.gov/pmc/articles/PMC1308345. Accessed April 12, 2012.
41. Osterman MJK, Martin JA, Mathews TJ, Hamilton BE. Expanded data from the new birth certificate, 2008. National Vital Statistics Reports. 2011;59:7. Hyattsville, MD: National Center for Health Statistics. Available at: www.cdc.gov/nchs/data/nvsr/nvsr59/nvsr59_07.pdf. Accessed April 12, 2012.
42. ACOG Committee Opinion No. 340. Mode of term singleton breech delivery. Obstet Gynecol. 2006;108(1):235–7. Available at: www.acog.org/Resources_And_Publications/Committee_Opinions/Committee_on_Obstetric_Practice/Mode_of_Term_Singleton_Breech_Delivery. Accessed April 12, 2012.
43. Lee et al. Population Trends in Cesarean Delivery for Breech Presentation in the United States 1997–2003. American Journal of Obstetrics and Gynecology. July 2008;199(1):59.e1–8. Available at: www.ncbi.nlm.nih.gov/pmc/articles/PMC2533265/?tool=pmcentrez. Accessed April 12, 2012.
44. American Academy of Pediatrics, Committee on Fetus and Newborn, American College of Obstetricians and Gynecologists and Committee on Obstetric Practice. The Apgar Score. Pediatrics. 2006;117:1444–7. Available at: http://pediatrics.aappublications.org/content/117/4/1444.full.pdf+html. Accessed April 12, 2012.
45. Snell et al. Reliability of birth certificate reporting of congenital anomalies. American Journal of Perinatology. May 1992;9(3):219–22.
46. Watkins et al. The surveillance of birth defects: The usefulness of the revised US standard birth certificate. American Journal of Public Health. 1996;86:731–4. Available at: www.ncbi.nlm.nih.gov/pmc/articles/PMC1380486/?tool=pubmed. Accessed April 12, 2012.
47. Buescher P, Taylor K, Davis M, Bowling J. The quality of the new birth certificate data: a validation study in North Carolina. American Journal of Public Health. August 1993;83(8):1163–5. Available at: www.ncbi.nlm.nih.gov/pmc/articles/PMC1695166. Accessed April 12, 2012.
48. Weisskopf, MG. Quality of birth certificate data on tobacco and alcohol use during pregnancy-Great Lakes Region, United States: 1989–1995. Presented at the CDC Epidemic Intelligence Service Conference. 2001.Department of Health and Human Services
State Center for Health Statistics
1908 Mail Service Center
Raleigh, NC 27699-1908
919-733-4728
State of North Carolina
Beverly Eaves Perdue, Governor
Department of Health and Human Services
Albert A. Delia, Acting Secretary
www.ncdhhs.gov
Division of Public Health
Laura Gerald, MD, MPH, State Health Director
www.publichealth.nc.gov
Chronic Disease and Injury Section
Ruth Petersen, MD, MPH, Chief
State Center for Health Statistics
Karen L. Knight, MS, Director
www.schs.state.nc.us/SCHS
The North Carolina Department of Health and Human Services does not discriminate on the basis of race, color,
national origin, sex, religion, age, or disability in employment or the provision of services. 06/12

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No. 19 June 2012
Revisions to the North Carolina Birth Certificate and
Their Impact on Tracking Maternal and Infant Health Data
by
Kathleen A. Jones-Vessey
Approximately every 10 to 15 years, standards for
collecting statistical information on U.S. birth certificates
are revised. These revised standards specify the data fields
collected on birth certificates and information that should
be reported to the Vital Statistics Cooperative Program
(VSCP). These standards serve as a model to ensure that
birth data are collected and reported in a uniform and
comparable manner across the United States. The latest
revision to the U.S. Standard Birth Certificate, finalized
in 2003, was devised by an advisory panel of experts
which included representatives from the National Center
for Health Statistics (NCHS), the Centers for Disease
Control and Prevention (CDC), state vital registration
and statistics executives, researchers and a variety of
interested data user organizations, such as the American
Medical Association (AMA) and the American Congress
of Obstetricians and Gynecologists (ACOG).1,2
From 1988 to 2010, the statistical information collected
on North Carolina’s birth certificates were based on the
1989 U.S. Standard Birth Certificate and entered into a
DOS-based electronic birth certificate (EBC) registration
system. The magnitude of the changes required to meet
the 2003 revised birth certificate standards necessitated
that North Carolina develop a more sophisticated birth
registration system. After years of complex system
development, in August 2010, the North Carolina’s Vital
Records office launched the web-based “Vital Records
Automation System” (VRAS) in delivery hospitals across
the state. VRAS was designed to improve the timeliness
of birth registration and Vital Statistics data dissemination
as well as to implement the 2003 U.S. certificate
standards.
Many of the data fields captured on the 2003 revised
birth certificate are modified or new. The purpose of this
report is to describe the new or modified information
collected on the 2003 revised version of the birth
certificate and highlight any significant differences with
the data fields captured on the previous version of the
birth certificate.
New Fields Collected on the North
Carolina Birth Certificate
● Facility and Attendant NPI [Items 31 and 32]:
As part of the Health Insurance Portability and
Accountability Act of 1995 (HIPAA), identifying
information on health care providers are collected
by the Centers for Medicare and Medicaid Services
Statistical Primer No. 19 ♦ June 2012 Division of Public Health
N.C. Department of Health and Human Services 2 State Center for Health Statistics
(CMS) and each provider is given a unique 10 digit National Provider Identifier (NPI).3 The revised birth certificate now includes NPI for the attendant as well as the facility where the delivery took place. The inclusion of NPI on the new birth certificate will facilitate linkage of the birth file with other healthcare databases.
● Pre-pregnancy Height and Weight [Items 36 and 37]: Obesity is a growing epidemic in North Carolina. According to the 2010 North Carolina Behavioral Risk Factor Surveillance System survey, over half (55%) of North Carolina women of childbearing age are classified as overweight or obese based on their Body Mass Index (BMI).4 Women who are obese during pregnancy may be at increased risk for a Cesarean section (C-section) delivery, longer hospital stays after delivery, gestational hypertension and diabetes, fetal death and birth defects.5 The previous version of the certificate recorded information regarding weight gain during pregnancy. However, without knowing pre-pregnancy weight and height, it was impossible to determine if the amount of weight gained during pregnancy was appropriate. As a result of increasing rates of obesity among women of childbearing age, current guidelines suggest that women who are overweight or obese going into pregnancy may not need to gain as much weight as women with normal BMI’s.6 The revised birth certificate collects information on the mother’s height, pre-pregnancy weight and weight at delivery. Using this data, weight gained during pregnancy can be computed and BMI can be calculated. This information will be used to report population-level information regarding obesity and the percentage of women gaining the appropriate amount of weight during pregnancy.
32
.ATTENDANT'S NAME, TITLE, AND NPINAME:----------------------------------------------------------------------------NPI:-----------------------------------------TITLE:MDDOCNM/CMOTHER MIDWIFEOTHER (Specify)------------------------------------------------31. FACILITY ID. (NPI)Items 31 and 3236.MOTHER'S HEIGHT37. MOTHER'S PREPREGNANCY------------------(feet/inches) WEIGHT ---------------(pounds)Items 36 and 37Item 3939. DID MOTHER GET WIC FOOD FORHERSELF DURING THIS PREGNANCY? YesNo
● Women, Infants and Children (WIC) During Pregnancy [Item 39]: WIC is a federal program that provides supplemental food, healthcare referrals and nutrition education for low-income pregnant, breastfeeding and postpartum women, and infants and children up to age 5 who are at nutritional risk.7 Prenatal WIC participation has been found to be associated with improved birth outcomes for disadvantaged women.8,9 The revised birth certificate includes a field for capturing whether the mother received WIC food for herself during pregnancy. Since 1988, the State Center for Health Statistics (SCHS) staff have performed an annual match of birth certificate data with state WIC records to gather information on this population. WIC information collected from the revised birth certificate will be compared with the matched data in order to assess the completeness of this data.
● Payment for Delivery [Item 43]: The revised birth certificate includes a field for capturing the principal source of payment for the delivery. Categories include private insurance, Medicaid, self-pay, and other (specified) insurance. Since 1988, North Carolina SCHS staff have matched all resident birth records with North Carolina Division of Medical Assistance Medicaid claims and enrollment files in order to determine deliveries paid by Medicaid.10 SCHS will use this matched
43
.PRINCIPAL SOURCE OFPAYMENT FOR THISDELIVERYPrivate InsuranceMedicaidSelf-PayOther(Specify)--------------------Item 43Statistical Primer No. 19 ♦ June 2012 Division of Public Health
N.C. Department of Health and Human Services 3 State Center for Health Statistics
data to compare with this information collected on the birth certificate in order to assess the completeness of this data.
● Mother’s Medical Record Number [Item 45]: The birth certificate is used as a basis for a variety of surveillance programs, including immunizations, newborn screening and birth defects. The addition of mother’s medical record number will facilitate data linkage with other health records, as well as ensure that maternal hospital records can be accessed without difficulty.
● Gestational Diabetes [Item 46]: The previous version of the birth certificate included a checkbox for maternal diabetes in the medical history section. However, there was no way to determine if the diabetes was pre-existing or developed during the pregnancy. In order to address this, the revised birth certificate now includes two separate fields for recording diabetes in the “Pregnancy Risk Factors” section. The first collects information for mothers who had diabetes prior to pregnancy. The second field is for mothers that developed high blood sugar during pregnancy (known as “gestational diabetes”). Mothers with gestational diabetes are at increased risk for birth injury, C-section delivery, high blood pressure during pregnancy and Type II (adult onset) diabetes in the future. Infants born to mothers with gestational diabetes are at increased risk for low blood sugar and infant death.11,12
● Fertility Treatments [Item 46]: The revised birth certificate now collects information regarding whether the pregnancy resulted from infertility treatment(s). This information is recorded through two separate fields. The first is a field for the use of fertility enhancing drugs, artificial insemination or intrauterine insemination. The second field is for the use of assisted reproductive technology such as in vitro fertilization (IVF) or gamete intrafallopian transfer (GIFT). Pregnancies achieved through infertility treatments may be at increased risk for multiple pregnancies which in turn, may place the mother at increased risk of complications, as well as greater risk of preterm, low birthweight and infant death.13,14 Utilizing data collected from the revised birth certificate, the State Center for Health Statistics will be able to assess the impact of fertility treatments on maternal and infant outcomes in North Carolina.
● Previous Cesarean Section [Item 46]: Cesarean sections have risen throughout the United States over the last decade.15 Women who have had prior C-sections are more likely to have another with subsequent deliveries. On the previous version of the birth certificate, the only method for determining whether a mother had a previous C-section was via the method of delivery (vaginal after C-section or repeat C-section). The revised birth certificate now includes an indicator for whether a mother had previous C-section(s) and for recording the number of previous C-sections.
● Infections During Pregnancy [Item 47]: The revised birth certificate includes a new section focusing on maternal infections present and/or treated during pregnancy. Specifically, it captures information on the following communicable diseases: gonorrhea, syphilis, chlamydia and hepatitis (B and C). Additionally, North Carolina
45.
MOTHER'S MEDICAL RECORD NUMBERItem 4546.RISK FACTORS IN THIS PREGNANCY(Check all that apply)DiabetesPrepregnancy (Diagnosis prior to this pregnancy)Gestational (Diagnosis in this pregnancy)HypertensionPrepregnancy (Chronic)Gestational (PIH, preeclampsia)EclampsiaPrevious preterm birthOther previous poor pregnancy outcome (Includesperinatal death, small-for-gestational age/intrauterine growth restricted birth)Pregnancy resulted from infertility treatment--If yes,check all that apply:Fertility-enhancing drugs, Artificial inseminationor Intrauterine inseminationAssisted reproductive technology (e.g., in vitrofertilization (IVF), gamete intrafallopian transfer(GIFT)Mother had a previous cesarean deliveryIf yes, how many ----------------None of the aboveItem 46Statistical Primer No. 19 ♦ June 2012 Division of Public Health
N.C. Department of Health and Human Services 4 State Center for Health Statistics
chose to add a field for recording testing for the Hepatitis B surface antigen (HBsAG)—including the test date and test results. Infants born to mothers with Hepatitis B infections are more likely to be born low birth weight and/or premature.16 The U.S. Preventive Task Force has concluded that HBV screening reduces perinatal transmission of HBV and recommends that all pregnant women be tested for HBV infection during their first prenatal visit.17 North Carolina Division of Public Health staff will use this information to assess whether HBV screening is taking place, as well as to determine the prevalence of prenatal infections.
● Maternal Morbidity [Item 52]: Another new section included on the revised birth certificate focuses on maternal complications associated with labor and delivery. This section includes fields for recording whether the mother required a transfusion, had a severe perineal laceration, ruptured uterus, unplanned hysterectomy, admission to the intensive care unit or an unplanned operating room procedure following delivery. None of this information was collected on the previous version of the certificate. Maternal labor and delivery complications can increase the costs associated with labor and delivery and may also put the mother at increased risk for postpartum complications and even death.18
● NICU Admission [Item 57]: The “Abnormal Conditions of the Newborn” section of the revised birth certificate now includes a field for whether or not the infant was admitted to the Neonatal Intensive Care Unit (NICU). This information has never been available at the state level and will allow Division of Public Health staff to determine the percentage of North Carolina newborns that require higher levels of care after delivery and might be at risk for morbidity, developmental delays and infant death.
● Infant Death [Item 60]: Infant mortality is considered one of the most important indicators of population health and well-being.19 In order to better understand the factors associated with infant death, the State Center for Health Statistics routinely matches all infant deaths with their matching birth certificate. Most infant deaths occur within the first few hours or days of life. In order to track infant deaths more quickly, the revised birth certificate now includes a field for recording whether the infant was living at the time the birth certificate was filed.
47.
INFECTIONS PRESENT AND/OR TREATED DURINGTHIS PREGNANCY (Check all that apply)GonorrheaSyphilisChlamydiaHepatitis BHepatitis CNone of the aboveWas mother tested for HBsAG? YesNoIf tested, include test date----------/----------/-------------------- MM DD YYYYand test results: PositiveNegativeItem 4752.MATERNAL MORBIDITY (Check all that apply)(Complications associated with labor and delivery)Maternal transfusionThird or fourth degree perineal lacerationRuptured uterusUnplanned hysterectomyAdmission to intensive care unitUnplanned operating room procedure followingdeliveryNone of the aboveItem 52Item 5757.ABNORMAL CONDITIONS OF THE NEWBORN(Check all that apply)Assisted ventilation required immediately followingdeliveryAssisted ventilation required for more than six hoursNICU admissionNewborn given surfactant replacement therapyAntibiotics received by the newborn for suspectedneonatal sepsisSeizure or serious neurologic dysfunctionSignificant birth injury (skeletal fracture(s),peripheral nerve injury, and/or soft tissue/solidorgan hemorrhage which requires intervention)None of the above60.IS INFANT LIVING AT TIME OF REPORT? YesoNInfant transferred, status unknownItem 60Statistical Primer No. 19 ♦ June 2012 Division of Public Health
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● Breastfeeding at Discharge [Item 61]: The U.S. Preventive Service Task Force concludes that there are “substantial health benefits for children and adequate evidence that breastfeeding provides moderate health benefits for women.” The Task Force recommends that interventions be put in place to support the initiation, duration and exclusivity of breastfeeding.20 Promoting breastfeeding is also a national public health priority. Healthy People 2020 includes several objectives related to increasing the proportion of infants who are breastfed.21 In an effort to track the prevalence of breastfeeding initiation, the revised birth certificate now records whether the newborn was being breastfed at hospital discharge. This data will allow North Carolina public health programs to track statewide, population-level, breastfeeding initiation rates for the first time.
Modified Fields Collected on the North Carolina Birth Certificate
In addition to new fields, the 2003 standard birth certificate also modified many of the existing demographic and medical information collected on the birth certificate. In many cases, these changes make comparisons between data collected under the previous version of the certificate and data collected under the revised certificate not comparable. Below are a list of fields which were modified with the revised birth certificate:
● Birthweight [Item 17]: On the previous version of the certificate birthweight was collected in pounds and ounces. On the revised certificate birthweight can be reported in grams or pounds and ounces.
● Mother’s and Father’s Race* [Items 20 and 21]: Prior to the 2003 revision, the race field on the birth certificate was open-ended and asked for the “Color or Race“ of both the mother and the father. The revised certificate does not mention color, specifies 15 discrete racial categories plus a category for “other,” and allows for the selection of more than one race.22,23 The 2003 revised birth certificate ethnicity reporting standards meet the race reporting standards defined by the Office of Management and Budget (OMB) in 1997.24 One additional change in race coding has also occurred. The National Center for Health Statistics (NCHS) population data sources do not include multiple race categories, therefore NCHS creates a crosswalk that “bridges” these multiple race categories back to a single race through imputation for the purposes of calculating consistent Vital Statistics rates.25 As part of this bridging process, race recorded for those of
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.IS THE INFANT BEING?EGRAHCSIDTADEFTSAERB YesNoItem 6117. BIRTHWEIGHT (grams preferred, specify unit)------------------------------------------------------------ grams zo/bl Item 1720.FATHER'S RACE (Check one or more races to indicate what the father considers himself to be)WhiteBlack or African AmericanAmerican Indian or Alaska Native(Name of the enrolled or principal tribe)--------------------------------------------------Asian IndianChineseFilipinoJapaneseKoreanVietnameseOther Asian(Specify)-----------------------------------------Native HawaiianGuamanian or ChamorroSamoanOther Pacific Islander(Specify)-----------------------------------------------Other(Specify)------------------------------------------------21.MOTHER'S RACE (Check one or more races to indicate what the mother considers herself to be)WhiteBlack or African AmericanAmerican Indian or Alaska Native(Name of the enrolled or principal tribe)--------------------------------------------------Asian IndianChineseFilipinoJapaneseKoreanVietnameseOther Asian(Specify)-----------------------------------------Native HawaiianGuamanian or ChamorroSamoanOther Pacific Islander(Specify)-----------------------------------------------Other(Specify)-----------------------------------------------Items 20 and 21Statistical Primer No. 19 ♦ June 2012 Division of Public Health
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Hispanic ethnicity has also been modified. Under race coding specifications for the previous version of the birth certificate, if a mother or father reported their race as “Hispanic,” NCHS guidelines typically stipulated that their race be classified as white. Under the 2003 revised race coding standards, the majority of Hispanics are now classified as “other races.”26 Due to this change in race coding for Hispanics, all reports based on North Carolina birth data will now be required to combine race/ethnicity (e.g., Non-Hispanic white, Non-Hispanic black, Hispanic, etc.).
● Mother’s and Father’s Ethnicity* [Items 25 and 28]: Race and ethnicity are recorded in two separate fields on both versions of the birth certificate. On the previous version of the birth certificate, ethnicity was a “yes/no” field that was followed by a separate question which specified the origin for those indicating that they were Hispanic. On the revised birth certificate, ethnicity and origin are recorded in the same field. The 2003 revised birth certificate ethnicity reporting standards meet the race and ethnicity reporting standards defined by the Office of Management and Budget (OMB) in 1997.24 The order of the race and ethnicity questions were also modified. Prior to generating the birth certificate, the mother is given a worksheet to fill out that includes demographic questions, such as race and ethnicity. On the mother’s worksheet, the ethnicity question is now asked prior to the race question, in an effort to improve the reporting of race for Hispanics.27
● Mother’s and Father’s Education* [Items 26 and 29]: The previous version of the birth certificate captured education levels by asking for the years of schooling completed. However, this method did not necessarily reflect degrees or diplomas received.27 To address this problem, the 2003 revision instead breaks secondary education into separate fields (8th grade or less, 9–12th grade, high school graduate or GED) and allows for reporting of specific degrees received (Associate, Bachelor’s, Master’s or Doctorate). Since education information is collected very differently on the two versions of the certificates, this field is not considered comparable across the two certificate revisions.
25.
FATHER OF HISPANIC ORIGIN? (Check thebox that best describes whether the father isSpanish/Hispanic/Latino. Check the "No" box iffather is not Spanish/Hispanic/Latino)No, not Spanish/Hispanic/LatinoYes, Mexican, Mexican American, ChicanoYes, Puerto RicanYes, CubanYes, other Spanish/Hispanic/Latino(Specify)----------------------------------------------28.MOTHER OF HISPANIC ORIGIN? (Check thebox that best describes whether the mother isSpanish/Hispanic/Latina. Check the "No" box ifmother is not Spanish/Hispanic/Latina)No, not Spanish/Hispanic/LatinaYes, Mexican, Mexican American, ChicanaYes, Puerto RicanYes, CubanYes, other Spanish/Hispanic/Latina(Specify)----------------------------------------------Items 25 and 2826.FATHER'S EDUCATION (Check the box thatbest describes the highest degree or level ofschool completed at the time of delivery)8th grade or less9th - 12th grade, no diplomaHigh school graduate or GED completedSome college credit but no degreeAssociate degree (e.g., AA, AS)Bachelor's degree (e.g., BA, AB, BS)Master's degree (e.g., MA, MS, MEng, MEd,MSW, MBA)Doctorate (e.g., PhD, EdD) or Professionaldegree (e.g., MD, DDS, DVM, LLB, JD)29.MOTHER'S EDUCATION (Check the box thatbest describes the highest degree or level ofschool completed at the time of delivery)8th grade or less9th - 12th grade, no diplomaHigh school graduate or GED completedSome college credit but no degreeAssociate degree (e.g., AA, AS)Bachelor's degree (e.g., BA, AB, BS)Master's degree (e.g., MA, MS, MEng, MEd,MSW, MBA)Doctorate (e.g., PhD, EdD) or Professionaldegree (e.g., MD, DDS, DVM, LLB, JD)Items 26 and 29
* In North Carolina, in cases where the mother was unmarried at the time of delivery, paternity must be established before the father’s information can be collected on the birth certificate. In 2010, 42 percent of all North Carolina births were to unwed mothers and 40 percent of these were missing father’s information on the birth certificate. For this reason, any demographic information collected for the father on the birth certificate (such as age, race, ethnicity, education and birth place) has a high rate of non-random missing data and is not suitable for analysis.Statistical Primer No. 19 ♦ June 2012 Division of Public Health
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● Place of Birth [Item 30]: The previous version of the certificate recorded information on place of birth which included hospital, freestanding birth center, clinic/doctors office, residence and other (specified). When deliveries occurred at a residence, it was difficult to determine whether the home birth was planned or unanticipated.27 To remedy this, the revised birth certificate changes the “residence” checkbox to “home birth” and includes a field for indicating whether the home birth was planned or not. Research indicates that unplanned home births have higher rates of adverse maternal and infant outcomes.28,29 Information regarding planned and unplanned home births in conjunction with information on the attendant at delivery will allow us to examine North Carolina home births in more detail.
● Attendant [Item 32]: The delivery attendant was recorded on both the 1989 and the 2003 standard certificates. The previous version of the certificate included the following attendant categories: Medical Doctor (M.D.), Doctor of Osteopathy (D.O.), Certified Nurse Midwife (C.N.M.), Other Midwife, and Other specified. The only change made to this field was the addition of “Certified Midwife” (C.M.) to the “Certified Nurse Midwife” (C.N.M.) checkbox. The revised certificate now includes: “C.N.M/C.M.” in the same checkbox. The American College of Nurse Midwives recommended this change because the licensing for both C.N.M.’s and C.M.’s are the same.27 This field will be used to better assess trends in delivery attendants over time, particularly the rise in CNM-attended deliveries. In 1990, C.N.M.’s attended 1.7 percent of North Carolina resident births, compared with 11 percent of all births in 2010.30,31
● Maternal Transfer [Item 33]: Both versions of the standard certificate report whether the mother was transferred prior to delivery, as well as the hospital of transfer. However the revised birth certificate added the stipulation: “for maternal medical or fetal indications for delivery.”
● Prenatal Care [Items 34a, 34b and 35]: The previous version of the certificate included a field for capturing the month that a mother initiated prenatal care. The revised certificate now asks for the complete date of the first prenatal care visit (month/day/year). The advisory group that made recommendations for the 2003 revised birth certificate felt that collecting the specific date care began would yield more accurate prenatal care data.27 The accuracy of this field is important as early initiation of prenatal care can help identify health conditions and risk factors which might impact the health of both the mother and infant.32,33
30
.PLACE WHERE BIRTH OCCURRED (Check one)HospitalFreestanding birthing centerHome Birth:Planned to deliver at Home? Yes NoClinic/Doctor's officeOther (Specify) ------------------------------------------Item 3032.ATTENDANT'S NAME, TITLE, AND NPINAME:----------------------------------------------------------------------------NPI:-----------------------------------------TITLE:MDDOCNM/CMOTHER MIDWIFEOTHER (Specify)------------------------------------------------Item 3233.MOTHER TRANSFERRED FOR MATERNAL MEDICALOR FETAL INDICATIONS FOR DELIVERY? Yes NoIF YES, ENTER NAME OF FACILITY MOTHERTRANSFERRED FROM:-----------------------------------------------------------------------------------Item 33Items 34a, 34b and 3534a.DATE OF FIRST PRENATAL CARE VISIT34b. DATE OF LAST PRENATAL CARE VISIT35. TOTAL NUMBER OF PRENATAL VISITS FOR THIS PREGNANCY----------/----------/-------------------- No Prenatal Care ----------/----------/-------------------- ---------------------------------------- (If none, enter "0".) MM DD YYYY MM DD YYYYStatistical Primer No. 19 ♦ June 2012 Division of Public Health
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● Weight at Delivery [Item 38]: The previous version of the certificate recorded information regarding weight gain during pregnancy. The revised birth certificate now collects information on the mother’s height and pre-pregnancy weight which are used in conjunction with the mother’s weight at delivery to calculate weight gained during pregnancy to determine if the mother gained the appropriate amount of weight during pregnancy. Research suggests that excessive weight gain during pregnancy leads to an increased risk of pregnancy complications, Cesarean section delivery and longer hospital stays after delivery.34
● Other Pregnancy Outcomes [Item 41]: Both versions of the birth certificate report whether the mother had prior fetal deaths, abortions or miscarriages. The previous version of the birth certificate reported the number of “other terminations (spontaneous and induced at any time after conception).” The revised birth certificate reports the number of “other pregnancy outcomes (spontaneous or induced losses or ectopic pregnancies).”
● Cigarette Smoking [Item 42]: Smoking during pregnancy may put women at increased risk for vaginal bleeding, placental problems, miscarriage and stillbirth. Infants born to mothers who smoked during pregnancy are more likely to have certain birth defects, be born premature and/or low birthweight and die from Sudden Infant Death Syndrome (SIDS).35,36 The previous version of the birth certificate included a “yes/no” checkbox regarding tobacco use during pregnancy and a separate field for recording the average number of cigarettes smoked per day. However, there was no means to determine whether the mother smoked prior to becoming pregnant or whether she ceased smoking at some point during her pregnancy. Research suggests that smoking cessation during pregnancy can reduce the incidence of low birth weight and hospital associated costs.37,38 The revised birth certificate includes fields for recording smoking status three months before pregnancy as well as during each trimester of pregnancy. This method of collecting smoking information on the revised birth certificate was selected based on research which determined that this was the most effective way to gather accurate maternal smoking behavior.39,40 Given the substantial changes in how this field is defined, the National Center for Health Statistics does not consider this field to be comparable with data collected through the previous version of the certificate.41
● Previous Preterm Birth [Item 46]: On the previous version of the birth certificate, there was a checkbox in the “Medical History for this Pregnancy” section for “previous preterm or small-for-gestational-age infant.” The revised certificate reports this in the “Risk Factors for This Pregnancy” section as: “previous preterm birth” and includes a separate check box for “other previous poor pregnancy outcome (includes perinatal death, small-for-gestational age/intrauterine growth restricted birth).”
● Hypertension [Item 46]: The previous version of the certificate included check-boxes in the “Medical History for this Pregnancy” section for chronic hypertension, pregnancy-related hypertension and eclampsia. The revised certificate reports hypertension in the “Risk Factors for This Pregnancy” section and labels them as prepregnancy (chronic), gestational (PIH, preeclampsia) and eclampsia.
38.
MOTHER'S WEIGHT AT DELIVERY----------------(pounds)Item 3841.NUMBER OF OTHERPREGNANCY OUTCOMESdecudni ro suoenatnops(losses or ectopic pregnancies)41a. Other Outcomes Number -----------None41b. DATE OF LAST OTHER PREGNANCY OUTCOME----------/----------MMYYYYItem 4142.CIGARETTE SMOKING BEFORE AND DURING PREGNANCYFor each time period, enter either the number of cigarettes or thenumber of packs of cigarettes smoked. IF NONE, ENTER "0"Average number of cigarettes or packs of cigarettes smoked per day. # of cigarettes # of packsThree months before pregnancy_____OR______First three months of pregnancy_____OR______Second three months of pregnancy_____OR______Third trimester of pregnancy_____OR______Item 42Statistical Primer No. 19 ♦ June 2012 Division of Public Health
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● Onset of Labor [Item 49]: The information collected in the “Onset of Labor” section of the revised birth certificate were previously collected in the “Events of Labor and Delivery” section of the previous version of the birth certificate.
● Characteristics of Labor and Delivery [Item 50]: Induction of labor and meconium were previously collected in the obstetrical procedures section of the previous version of the birth certificate. “Non vertex presentation” was collected as “breech/malpresentation” in the “events of labor and delivery” section of the previous version of the birth certificate. “Clinical chorioamnionitis diagnosed during labor” was collected as “febrile >100F or 38C” on the previous version of the birth certificate.
● Method of Delivery [Item 51]: The previous version of the certificate included a checkbox for method of delivery which had fields for vaginal, vaginal birth after C-section, Primary C-section, Repeat C-section, forceps and vacuum deliveries (certifiers could check all that applied). The revised certificate includes additional information regarding fetal presentation (cephalic, breech, other), whether forceps delivery was attempted and unsuccessful, whether vacuum delivery was attempted but unsuccessful and whether a trial of labor was attempted prior to Cesarean section delivery. C-section deliveries have risen 37 percent from 22.9 percent of resident births in 1990 to 31.4 percent in 2010.30,31
46.RISK FACTORS IN THIS PREGNANCY(Check all that apply)DiabetesPrepregnancy (Diagnosis prior to this pregnancy)Gestational (Diagnosis in this pregnancy)HypertensionPrepregnancy (Chronic)Gestational (PIH, preeclampsia)EclampsiaPrevious preterm birthOther previous poor pregnancy outcome (Includesperinatal death, small-for-gestational age/intrauterine growth restricted birth)Pregnancy resulted from infertility treatment--If yes,check all that apply:Fertility-enhancing drugs, Artificial inseminationor Intrauterine inseminationAssisted reproductive technology (e.g., in vitrofertilization (IVF), gamete intrafallopian transfer(GIFT)Mother had a previous cesarean deliveryIf yes, how many ----------------None of the aboveItem 4649.ONSET OF LABOR (Check all that apply)Premature Rupture of Membranes(prolonged,>12 hrs.)Precipitous Labor (<3 hrs.)Prolonged Labor (> 20 hrs.)None of the aboveItem 4950.CHARACTERISTICS OF LABOR AND DELIVERY(Check all that apply)Induction of laborAugmentation of laborNon-vertex presentationSteroids (glucocorticoids) for fetal lung maturationreceived by the mother prior to deliveryAntibiotics received by the mother during laborClinical chorioamnionitis diagnosed during laboror maternal temperature > 38°C (100.4°F)Moderate/heavy meconium staining of the amnioticfluidFetal intolerance of labor such that one or more ofthe following actions was taken: in-uteroresuscitative measures, further fetal assessment,or operative deliveryEpidural or spinal anesthesia during laborNone of the aboveItem 50Item 5151.METHOD OF DELIVERYA.Was delivery with forceps attempted but unsuccessful?YesNoB.Was delivery with vacuum extraction attempted butunsuccessful?YesNoC.Fetal presentation at birthCephalicBreechOtherD.Final route and method of delivery (Check one)Vaginal/SpontaneousVaginal/ForcepsVaginal/VacuumCesareanIf cesarean, was a trial of labor attempted?YesNoStatistical Primer No. 19 ♦ June 2012 Division of Public Health
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● Fetal Presentation at Birth [Item 51]: The previous version of the birth certificate included a field for recording breech/malpresentation in the “events of labor and delivery section.” The revised certificate provides greater specificity regarding whether the child was cephalic, breech or other. Cesarean section delivery is typically recommended in cases of fetal malpresentation.42,43 This information will be used to assess birth and method of delivery outcomes for infants born after fetal malpresentation in North Carolina.
● Obstetric Estimate of Gestation [Item 54]: The previous version of the birth certificate labeled this field as “clinical estimate of gestation.”
● Apgar Score [Item 55]: The Apgar score is a method for quickly assessing the overall health of a newborn right after delivery. The Apgar ranks newborn health with regard to skin color/complexion, reflexes, muscle tone, breathing and pulse rate. Newborns are typically assessed within minutes after birth. The previous version of the certificate recorded both one and five minute Apgar scores. Research has concluded that one minute Apgar scores alone are not a valid predictor of an infant’s future outcome. Five minute Apgar scores have been determined to be better predictors of neonatal risk and mortality. Low Apgar scores at five minutes should be repeated every five minutes up to 20 minutes.44 As a result of this research, the revised birth certificate standard now records a five minute Apgar and only records the Apgar at 10 minutes if the five minute Apgar score was low (defined as less than six).
● Abnormal Conditions of the Newborn [Item 57]: The label for this section changed from “Conditions of the Newborn” to “Abnormal Conditions of the Newborn.” The previous version of the birth certificate included two categories for assisted ventilation: 1) <30 minutes and 2) >= 30 minutes. The revised birth certificate has two different categories: 1) ventilation required immediately following delivery and 2) ventilation required for more than six hours. The previous version of the birth certificate included a checkbox for seizures. The revised birth certificate changed this to “seizures or serious neurologic dysfunction.” The previous version of the birth certificate included a checkbox for birth injury. The revised birth certificate modifies this checkbox to: “significant birth injury” and includes examples of what this might include.
● Congenital Anomalies [Item 58]: Research suggests that congenital anomalies have not been reliably recorded on past revisions to birth certificates.45,46 In an effort to improve reporting, the Advisory Panel that devised the specifications for the 2003 birth certificate revision carefully examined deficiencies in how congenital anomalies were captured on prior certificates. According to the Advisory Panel, the 2003 revised certificate only includes anomalies that meet the following criteria: “1) the anomaly is diagnosable within the first 24 hours following birth using widely available conventional diagnostic techniques, 2) occurrence will indicate the need for a specific public health initiative, 3) occurrence serves as a potential marker for teratogen exposure, 4) occurrence in live borns is affected by prenatal diagnosis or management and 5) postnatal outcome is
Item 54
54.OBSTETRIC ESTIMATE OF GESTATION:------------------------------------ (completed weeks)Item 5555.APGAR SCORE:Score at 5 minutes: -----------------------------------If 5 minute score is less than 6,Score at 10 minutes: ---------------------------------Item 5757.ABNORMAL CONDITIONS OF THE NEWBORN(Check all that apply)Assisted ventilation required immediately followingdeliveryAssisted ventilation required for more than six hoursNICU admissionNewborn given surfactant replacement therapyAntibiotics received by the newborn for suspectedneonatal sepsisSeizure or serious neurologic dysfunctionSignificant birth injury (skeletal fracture(s),peripheral nerve injury, and/or soft tissue/solidorgan hemorrhage which requires intervention)None of the aboveStatistical Primer No. 19 ♦ June 2012 Division of Public Health
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heavily impacted by access to tertiary or quaternary care resources.”27 Congenital anomaly information identified on the revised birth certificate will be compared to the North Carolina Birth Defects Monitoring Program registry data to assess if the accuracy of congenital anomaly data collected through the revised birth certificate improves as a result of these reporting changes. Specific modifications to this section include the following:
The previous version of the birth certificate had a checkbox for “anencephalus” and the revised birth certificate changes this to “anencephaly.” The previous version of the birth certificate had a checkbox for “spina bifida/meningocele” and the revised birth certificate changes this to “meningomyelocele/spina bifida.” The previous version of the birth certificate had a checkbox for “heart malformations” and the revised birth certificate changes this to “cyanotic congenital heart disease.” The previous version of the birth certificate had a checkbox for “diaphragmatic hernia” and the revised birth certificate changes this to “congenital diaphragmatic hernia.” The previous version of the birth certificate had a checkbox for “omphalocele/gastroscihsis” and the revised birth certificate separates these into two separate fields “omphalocele” and “gastroschisis.” The previous version of the birth certificate had a checkbox for “polydactyly/syndactyly/adactyly” and the revised birth certificate modifies this to just “limb reduction defect (excluding congenital amputation and dwarfing syndromes).” The previous version of the birth certificate had a checkbox for “cleft lip/palate” and the revised birth certificate separates these into two separate fields “cleft lip with or without cleft palate” and “cleft palate alone.” The previous version of the birth certificate had a checkbox for “Down’s syndrome” and the revised birth certificate includes this, but further specifies “karyotype confirmed” and “karyotype pending.” The previous version of the birth certificate had a checkbox for “other chromosomal anomalies.” The revised birth certificate also has “suspected chromosomal disorder,” and additionally specifies “karyotype confirmed” and “karyotype pending.” The revised birth certificate has a checkbox for hypospadias. On the previous version of the birth certificate this information may have been collected via two different checkboxes, one for “malformed genitalia” and another for “other urogenital anomalies.”
● Infant Transfer (Item 59): Both versions of the birth certificate include fields for reporting if the infant was transferred to another facility. The revised birth certificate further specifies whether it was “within 24 hours of delivery.”
Fields that have been Eliminated with the 2003 Revision
● Alcohol Use During Pregnancy: The previous version of the birth certificate included an indicator for whether the mother consumed alcohol during pregnancy as well as the average number of alcoholic drinks consumed per week during pregnancy. Prior research with the 1989 revision to the North Carolina birth certificate data indicated that this field was not reliably reported.47 Other research confirmed substantial underreporting and inconsistency with prenatal drinking reported on national health surveys.48 Based on this research, the Advisory Panel that created the specifications for the 2003 birth certificate revision concluded that: “it is not feasible to get quality data on the birth certificate because of the stigma attached to alcohol use during pregnancy.” The Advisory
Item 58
58.CONGENITAL ANOMALIES OF THE NEWBORN(Check all that apply)AnencephalyMeningomyelocele/Spina bifidaCyanotic congenital heart diseaseCongenital diaphragmatic herniaOmphaloceleGastroschisisLimb reduction defect (excluding congenitalamputation and dwarfing syndromes)Cleft Lip with or without Cleft PalateCleft Palate aloneDown SyndromeKaryotype confirmedKaryotype pendingSuspected chromosomal disorderKaryotype confirmedKaryotype pendingHypospadiasNone of the anomalies listed aboveItem 5959.WAS INFANT TRANSFERRED WITHIN 24 HOURS OF DELIVERY? YesNoIF YES, NAME OF FACILITY INFANT TRANSFERRED TO:--------------------------------------------------------------------------------------------------------------Statistical Primer No. 19 ♦ June 2012 Division of Public Health
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panel recommended that this data be obtained from national health surveys, such as the Pregnancy Risk Assessment Monitoring System (PRAMS).27
● Medical History: Based on Advisory Panel recommendations, several maternal conditions were eliminated from this section of the certificate (in the 2003 revision, this section was relabeled “Risk Factors in this Pregnancy”). Conditions that did not meet the following criteria were eliminated: “1) clearly defined clinically, 2) collectable at least 90 percent of the time, 3) evidence-based, 4) useful for research (public health and clinical) purposes, 5) potential to effect pregnancy outcome, and 6) required by legal statute.”27 Using this criteria, the following maternal conditions were eliminated: anemia, cardiac disease, acute or chronic lung disease, genital herpes, hydramnios/obligohydramnios, hemoglobinopathy, incompetent cervix, previous infant 4000+ grams, renal disease, Rh sensitization and uterine bleeding.
● Events of Labor and Delivery: Based on Advisory Panel recommendations, this section of the certificate was also significantly modified (in the 2003 revision, this section was relabeled “Characteristics of Labor and Delivery”). The Advisory Panel recommended that the following fields be eliminated from the 2003 revised birth certificate: meconium moderate or heavy, abruption placenta, placentia previa, other excessive bleeding, seizures during labor, dysfunctional labor, cord prolapse, anesthetic complications and fetal distress.
● Conditions of the Newborn: The Advisory Panel recommended removal of newborn conditions from the birth certificate: 1) that are not easily diagnosed within the first 24 hours following delivery, 2) which do not have high associations with adverse neonatal and long-term outcomes and 3) markers for utilization of costly technological resources.27 Based on this criteria, the following newborn conditions were removed from the revised birth certificate: anemia, fetal alcohol syndrome, hyaline membrane disease/RDS and meconium aspiration syndrome.
● Congenital Anomalies: As outlined in the congenital anomalies modifications section above, the Advisory panel determined that many of the congenital anomalies reported on the previous version of the birth certificate were not reliably reported.27 As a result, the following congenital anomaly fields are no longer collected on the 2003 revised birth certificate: hydrocephalus, microcephalus, other central nervous system anomalies, other circulatory/respiratory anomalies, rectal atresia/stenosis, tracheo-esophageal fistula/esophageal atresia, other gastrointestinal anomalies, renal agenesis, other urogenital anomalies, club foot, other musculoskeletal/integumental anomalies and other chromosomal anomalies.
● Other Specified Diagnoses and Conditions: The previous version of the birth certificate collected additional diagnostic information in the “other specified” fields of the medical history, obstetric procedures, events of labor and delivery, conditions of the newborn and congenital anomalies of child sections. The revised birth certificate has eliminated these free text fields because they do not result in uniform data that can be coded and utilized by states.27
New and Modified Fields Collected for Legal and Vital Registration Purposes
Some additional fields that are not necessary for medical or health research, but are helpful for legal and vital registration purposes have also been added or modified on the revised birth certificate. Below is a list of these fields:
● Mother Last Name (Current and Prior to First Marriage) [Items 9a and 9c];
● For Unmarried mothers, whether a paternity acknowledgement was signed in the hospital [Item 22].
Reporting Data Based on the Revised Birth Certificate in North Carolina
In 2010, North Carolina’s Vital Records office began implementing a new birth registration based on the 2003 revised birth certificate standard. Training in the Statistical Primer No. 19 ♦ June 2012 Division of Public Health
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new web-based birth registration system was rolled out in August 2010, hospital by hospital. By the end of 2010, all hospitals in the state were transmitting birth data to the state Vital Records office through the new registration system. As a result of this staggered implementation, North Carolina birth data were collected under both the 1989 and the 2003 birth certificate standards in 2010. Therefore, the State Center for Health Statistics was unable to publish any data from the new or modified fields for 2010 births. Fields that were not comparable across the two certificate revisions, such as maternal smoking, prenatal care and congenital anomalies were left blank in the 2010 birth file and were not reported in the 2010 Vital Statistics reports. Beginning in 2011, birth data were collected solely under the revised U.S. Standard Certificate, therefore, 2011 will represent the first full year of revised birth certificate data that North Carolina’s State Center for Health Statistics will publish. Researchers and other data users of North Carolina birth data will need to be careful not to compare trends in certain key public health indicators, such as prenatal care, race, smoking and maternal education levels, across the two revisions.
References
1. National Center for Health Statistics, Division of Vital Statistics, Reproductive Statistics Branch. 2003 Revisions of the U.S. Standard Certificates of Live Birth and Death and the Fetal Death Report. Hyattsville, MD: Available at: www.cdc.gov/nchs/nvss/vital_certificate_revisions.htm. Accessed April 12, 2012.
2. National Center for Health Statistics, Division of Vital Statistics, Reproductive Statistics Branch. The New Birth Certificate: Making Vital Statistics More Vital. Hyattsville, MD: Available at: www.cdc.gov/nchs/ppt/dvs/THE%20NEW%20BIRTH%20CERTIFICATE.ppt. Accessed April 12, 2012.
3. Centers for Medicare and Medicaid Services (CMS). National Provider Identifier Standard (NPI). Available at: www.cms.hhs.gov/Regulations-and-Guidance/HIPAA-Administrative-Simplification/NationalProvIdentStand/index.html?redirect=/NationalProvIdentStand. Accessed April 12, 2012.
4. North Carolina Department of Health and Human Services, Division of Public Health, State Center for Health Statistics. Tracking Preconception Health in North Carolina: 2010. Available at: www.schs.state.nc.us/schs/data/preconception.html. Accessed April 12, 2012.
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